HSCI 537                                                                                            Dr. Robert Huff

CSU Northridge

Course Facilitator          

(818) 677-2997

VIDEO AND PHOTOGRAPHIC PERMIT

Media Production Title: ___________________________________________

The undersigned does hereby authorize the HSCI 537 Media Production Team to videotape and/or photograph or permit other persons to videotape and or photograph myself, and further agree that they may only use or permit others to use the videotape and/or photographic images or negatives of myself for the media production identified above.

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Signature of Subject                                                                              Date

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Signature of Witness                                                                             Date

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Signature of Witness                                                                             Date